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Thursday, July 21, 2011

Choosing a Medical Specialty Is Difficult

A blog that was posted two months ago just came to my attention. On the KevinMD website, a physician wrote about the trials and tribulations of emergency medicine. The piece was a description of how the author chose her specialty. Looking for balance between work and family, the author picked EM because she “…thought the shift work in EM would allow me to have the best of both worlds.” After she had children, she discovered that juggling career and family responsibilities caused significant emotional and physical stress. It turns out that emergency rooms are open 24 hours per day and seven days per week. This necessitates staffing even in the wee hours of the morning. This “…did not fit well with family life.”

She goes on the say “Is the toll that working odd hours [takes] worth it? Is the exhaustion EM physicians experience jeopardizing patient safety?”

The author asks, “What are possible solutions to this problem since the highest need for EM clinical coverage is in the evenings and nights when office-based doctors have already gone home?” I can’t think of many.

There are two major issues.

1. Work hours. Hold on a minute, I thought the fuss was about docs working inordinately long hours, like 30 at a time. You mean to tell me that even a 12 hour shift [the longest stretch that any ED MD has to work] causes exhaustion to the point of jeopardizing patient safety? How can this be? Don’t let the ACGME find out or everyone will be working 4-hour shifts.Can we close emergency rooms at, say, 5 pm? I’m not sure the public will buy into that since they are already up in arms about all things related to medical care. And who would order the CT scans?

2. Family considerations. With a few exceptions such as dermatology, radiation medicine and rehabilitation medicine, all medical specialties interfere with family life. Either practice one of the previously mentioned “9 to 5” specialties or consider a career change.

49 comments:

How is her case any different than a college student who joins the National Guard, but is upset when they get deployed? ED medicine has not changed significantly in the last 30yrs to the best of my knowledge.

I would also point out that there are A LOT of jobs that pay poorly and still have 12 hour shifts. I would love to see her tell my friends that do concrete, or build windows, that at over triple their compensation that she needs special treatment.

As you said there are specialties that are more conducive to a 9 to 5 lifestyle. The problem in this case is not the job, it is the employee.

Having "M.D." at the end of your name is not an automatic exemption from having to live with the results of your life choices, both good and bad.

Thanks for your comments. How could I have omitted allergy, prev. med. & cosmetic surg? Good point about the national guard. Emergency medicine has changed in one respect. EDs are much busier now than they were 30 years ago.

The good is that you can go part time easily. You don't take call. You can swap shifts as needed. You can switch jobs easily. The bad, nights, evenings, weekends, and holidays. You CAN work 9-5 in an academic setting but for less $$.

Medicine is not a dilettante's profession. Make the commitment or get out. I think the solution lies in more discriminating admissions practices at the medical school level, with emphasis on selecting candidates who demonstrate a commitment to medicine above other concerns. The day first-year students start talking about the "lifestyle specialties" is the day we should throw them out. Also, love the blog. Keep it up.

Yes, they are many other jobs that require long hours especially in this economy. Many do not pay as well (thought I truly believe doctors should be paid more - with the insurance costs they bear and the years of education to pay off).Women of all types of careers have to make these choices daily. Bring home the bacon or spend more time with family. The choice becomes mute when the husband is laid off or if there is a just one parent to take care of the children. We all make the best of what we have and can do.Dermatology or geriatrics are an excellent choice for her - she would have more control of the hours.

Funny all of this. My previous career, corporate and a business owner for some time had me working much more than most of ya. But I did get all the $ and did enjoy it for many years. Thing is, in medicine you have to decide what you want to do. You either have your own practice or work for "The Man" - trade-offs for both. You need to know in what way you will be "allowed" to work before you choose your specialty. Kinda like the real world, huh. Glad I started my worklife outside of medicine. And, although nursing can be irritating, at least I have many options - even corporate again, should I choose.

If you kicked all of the women who want to balance time with their children out of medicine you would be left with a much less rich and caring group of doctors. They provide something special and medicine would do well to accomodate them as much as possible.

speaking as one who is -- as rarely as i can manage -- a patient... if i have angina, or am bleeding, i thiiink that a real expert who is short on sleep and stressed by the kids at home would be really preferable to just hanging out at home hoping (respectively) that the chest pain goes away, or that the platelets will kick in on their own.

mr. scalpel, i like your suggestion about the navy work hours. interesting food for thought. here's another one. what if every physician began his or her career with a 6-year em 'tour of duty', with the option for those who love it to repeatedly 're-enlist'? in em in particular, there's no patient expectation of consistency in care. no one has a 'primary' em doc. so why not fill the need with waves of new 'recruits'? yeah, silly and extreme. but how silly is it? is there a scaled-back version of the idea that could work? what if all student loan repayment was deferred for those six years, and the em staffers had the possibility of paying on their principal balances during their em time? and of course there would need to be sensible criteria for exceptions that wouldn't be too easy to meet.

there are lots of jobs that are very necessary, excellent training, and at the same time high burnout. maybe we should encourage docs to spend their entire career in em, but not expect them to.

Listen you "old school docs" you people have destroyed health care as we know it. We are no longer going to work 80hr per week for no pay. The new generation its tired of working our butts off just to see or compensation decrease year after year. We are going to take our profession back from the insurance companies.

Has anyone ever heard of the servant mentality? When we chose medicine as a career did we not have a clue to the responsibilities that come with that choice? Come on! Our altruistic bent with a little co-dependency rolled in for good measure makes for some rewards that most people cannot even imagine. The tearful mother to whom you have restored a very ill child? What does that do for your heart? Oh, you say, the nanny called and my child has a temperature of 101 and a tummy ache in the lower right quadrant? A hot appendix? Oh my, what shall we do? You do what all reasonable parents do, you seek medical care. What is so hard about that?Choosing a practice based on how much free time I will have available to go after what I really want to do is not the kind of doctor I want taking care of my loved ones. If dedication to the profession is a problem the student needs to be sent packing. They are obviously in the profession for what they see as easy money!

To Anon - if the servant profession is such burden get out already! I do not see a leashkeeping you from pursuing your unrealistic dreams. Seldom does a cardiac event choose the hours between 0900 and 1600 to manifest. That is why we chose our noble profession! To be able to meet these untimely events!

To _sahirs,I disagree with your statement that being a doctor is no more commitment than an engineer or a support technician. I doubt that many engineers are called out of bed at 2 am to save a life or even as in my case last night, to insert an IV because no ED MD could do it.

Im a surgical resident from argentina, our on call time is 24 hours. We work for 700 us dollars a month. Were forced to be in the er 2 days a week and none of us go home before 17.00. So, for all of those who think doctors dont commit more than other professionals, first learn about what sacrifices an md does. We have the responsability of the health of our patients, on our hands.

A minor aside..but no cosmetic/aesthetic surgeons I work with have 9-5 hours. Even discounting the evening/weekend hours spent on clinics, paperwork, and business management, they share the responsibility, common to all surgeons, of full postoperative care, including complications that may require emergent management at any hour. Yes, aesthetic surgeons are not doing E1 laparotomies at 2am, but it is still not a field for someone who wants 40 hour weeks.

First off, as an M2 I disagree with Anon #1 about stricter screening of med students. This woman’s problem was in her chosen specialty, that doesn’t mean she can’t be a good physician. It seems to me that she just chose poorly and while I do think it’s bit ridiculous that she didn’t know better, we students also only get a couple months in a specialty before we are supposed to decide what we want to do for the rest of our lives. Some know before they ever enter school, but I also know people who said they were absolutely positive they didn’t want to do a certain specialty and a couple years later ended up choosing that same specialty. And one must realize, many of us (not myself) are roughly 26 years old making these decisions, before we have any idea of what it takes to have a successful marriage and family. Women that choose to go into medicine do have a lot more things to consider; fair or unfair, biology has dictated that. Which brings me to another point to those that think my generation’s doctors (particularly surgeons) are “soft” or “weak”. Society and the economy is different today, most families that are fortunate enough to still have both parents under the same roof can’t financially afford NOT to have both those parents working. My generation doesn’t have the luxury of previous generations that were the traditional make-up where the man goes to work, the woman stays home, and that was that.On the navy work hours, I’m assuming you’re being sarcastic. Those hours are set for a very specific niche, one that needs to be constantly watchful of someone trying to harm them and everyone is confined on a ship with nothing else to do anyway. Those hours are not conducive to a “normal” life (e.g. they don’t have to consider families, there aren’t any around), nor are they kept for any length of time close to a lifetime, hence deployments tend to be 6 months. But work hours do need to be addressed (see below).To the Anon that mentioned “tours of duty”, not only is that comparable to a draft in which we would actually be paying hundreds of thousands of dollars to be a part of, I really don’t think you want every med student to be in the ED. I know many classmates that just couldn’t handle the gore or stress that EM provides.And I don’t think you “old docs” destroyed medicine, in fact, medicine today is what its is because of you, good and bad yes, but one should remember that we also have the best healthcare in the world. But I truly do hope the days of working for what amounts to a couple dollars an hour are gone for good. It was completely unfair to your generation that you were compensated in such a way for what is one of the most demanding jobs ever. In just one year of med school I have realized many sacrifices that I have had to make in my life to get here, and I realize that there are going to be a lot more. And while yes, it is also one the noblest professions, I don’t think it’s right to ask of us to sacrifice the best years of our lives, our families, even our health, and saddle us with hundreds of thousands of dollars debt just for the privilege of saving lives or so we can go on to not have a good family life.And to whomever thinks being a doctor is no more noble than an engineer, you obviously have never worked as both (see above paragraph). I personally feel being a physician, a good one, is the most noble AND the most stressful job in the world, but I am biased for sure. To comment on something I know Dr. Scalpel has mentioned before, I believe being a surgeon is even more stressful than an airline pilot, the commonly reported most stressful job. A more proper comparison would be more like the pilot magically finding himself beamed into a plane at 30,000 feet and the plane has some kind of mechanical malfunction; oh and the pilot has to go out on the wing and fix it himself, or everyone dies. Again, I’m probably biased.

Eastwood, thanks fr the great comments. You make some very god points. Yes, I was exaggerating about working Navy hours. Many thought I was serious though. It must be difficult being a med student now, especially if you are a woman. I wish you all the best of luck.

While I am not a physician I worked closely with general surgeons for many years and agree with Dr. Eastwood, The work of (good) surgeons is close to heroic...And they do it every day! Grace under pressure. . that describes surgeons.DD

Since you are so senior to me, let me ask you for your thoughts. I got into medical school, studied ,worked hard, got into residency and learnt, spent hours and hours in hospital, loved critical care and got into fellowship. Along the way met a guy ( both were residents at that time) ,fell in love and we both dreamt and read and learnt and discussed cases. He decided on cardiology and I decided on critical card. Both got into fellowships ....worked hard, spent long hours into fellowship...we were committed. We ARE committed but divided.... We had kids and now everyday i I feel divided. I have a feeling that all "old timers " like you who worked formlongerbhours and did frequent niight calls , had " spouse" who take care of your kids and you did not have to worry as much. Times were different. Times were not so dangerous and kids safety outside of the house was not so concerning. In my situation, me and my spouse are both physicians in fields that requires us to spend lots and lots of hours in hospital. If I were to find a traditional practice and work every 3 rd might" who will raise my kids. Who will teach them right from wrong. Everything is on rise- drug abuse, physical abuse, drop out rates. I WANT to raise my kids and be there to guide them . So yes I want a practice where call frequency is lesser, where I can spent evening with my kids ( not because I want to have fun but I want to be there) . We do not think about all this when we get into medical school and I did not think about this when i married my husband and we did not think about this when we chose our subspecialities. Perhaps that was a mistake.

As some one that has an undiagnosed medical problem I have to look at the question as what ever Medical Specialty one choses then need to put many hours kepping up with all the new studies related to that specialty. As to a Dr having a 9 to 5 job if that is all the time they are spending then they just are not doing there job.

Medicine is not a job that you go into for money. Medicine is a passion. You have to want the best for you patients. If you choose medicine it is a choice that will dictate not accommodate your life. You should have figured that out before you even applied for medical school.

As an Australian intern, I found that working an 8 hour shift in the EM was far more exhausting than working a regular 12 hour shift on the surgical ward. EMs are MUCH busier than they used to be. In Australia, the pressure to get patients up into a (bedblocked) ward before the 4 hour time limit imposed by bureaucrats is enormous. Juggling four undifferentiated patients at once is a completely different prospect to juggling 12 or 13 mostly stable surgical patients whose problems you have a good handle on. Towards the end of shift, I simply feel as though I don't have the concentration span left to adequately get a fix on a complex patient's problem.

This is probably more of a junior doc issue, as I see terrific EM consultants handling 6-7 patients at once with ease - but they still experience extraordinary stress and pressure, even if they do get to leave it all behind at the end of their shift...

I think the problem in EM is that there is only so much new information in relation to a totally unknown patient that you can process in a certain period of time, and still perform well. That is the fundamental difference between EM and ward work, at a junior level at least.

I used to think that I wanted to specialise in EM, given it seemed relatively flexible, but after my intern rotation I realised I simply hadn't comprehended the toll it took on me. I still work a day a week in EM and really enjoy it, but I doubt I'll specialise in the field. I think I am just lucky that I realised all these things before I chose it as a specialty, perhaps unlike the author of the post.

My response to the article in the WSJ in 2011 and the comment it elicited. http://drdarrellwhite.com/tanstaafl-and-mommy-track-docs/

The bilious responses on KevinMD.com when it was reprinted were of the same kind. The facts are the facts. Every physician makes a choice and every choice has consequences. Once upon a time there was an additional type of compensation showered upon us: respect and recognition for both our knowledge and the significant sacrifices we'd made and continued to make. By and large this "compensation" is no longer a part of the equation, and thus the calculus of whether our sacrifices at all points of the journey is dramatically different.

Even for dinosaurs like us it really DOES feel more like a job now, doesn't it?

The entire healthcare system, in all respects, is being bourn on the backs of mid-career docs of both genders who continue to behave in their practice lives as if we still live in a world that treats us like it is 1982. As we retire, cut back our hours (as I admit I've done), reduce the amount of work we do per hour (ditto), the true cost of the work/life balance compromise will be dramatically exposed.

Lots of great comments, I am having fun reading this blog. I chose plastic surgery because I found it fascinating. I set my practice up in St Louis because it was the best place for my family at the time. With that being said I think your specialty chooses you as much as you choose it. specialties have changed over the years and I think they will continue to do so.

Thank you so much for this blog, it really opened my eyes in choosing a specialty. I went into medical school mostly because there wasn't a lot of opportunities for my pre-med course. ( I know, it wasn't a very good reason, but there you have it.) However, along the way, I learned to really love my new "job", sure clerkship and internship were sucking my social life out but just that one heartfelt thank you from a mom whose child you were able to revive beats all the exhaustion away. ( I worked in a government hospital so when I say 36 hr duty, I really do mean a 36-hour duty). After internship,I was all set to become the greatest internist (neurologist) out there!

But after passing the board exam, I became confused. Now, i'm not so sure about it because i think even after residency, i wouldn't be able to have much of a life outside of the hospital..am i getting this right?

So now I have read all the comments here and one thing really stood out for me. Choosing medicine will dictate my life. Scary thought. But thank you for it. I am a female physician who wishes to have a family someday but i think until that day comes, i shouldn't plan my chosen specialty around it. I'll try to see how my life will be doing something i'm good at, really love doing and train to become better if not the best at it. If and when I doget around to having a family, i'll cross that bridge when I get there.

Thanks again, i'll continue to follow your blogs, they are truly very helpful.

Ya know, the following line that I keep reading is really starting to grate on me: "you should have figured that out before you even applied to medical school". So I won't bother to even address it.

What I WOULD like to address is where exactly is this field going? What will the surgical profession resemble in the next hundred years? Will it go back to simply being overworked, jaded, harsh barbers with sharp knives? Because that's pretty much where it seems to be now. Don't get me wrong; I love the field. But, I also love macaroni and cheese and motorcycles, both of which would kill me given similar excess which is required for this career. The suicide rate is real, and it scares me. The question isn't just whether my family is more important than my career or my patients...it is whether I am. I am the only me that I get to be. And, death is coming whether I'm a surgeon or not.

As far as fixing modern health care that the "old timers" screwed up...well, it's pretty simple. Abolish the patient's right to sue. Place the emphasis back on actually being a good physician and a good person (shocker, I know) that patients can trust, and let the capitalist fundamentals work their magic.

Very intereting discussion happening here! I am a gymnasium (last year) engineering student who's got many possibilities ahead, and one of them is medical university (if I can pass Biology- and chemistry classes after the Gymnasium). Since my knowlegde in math is very VERY low, I'm starting to find some interest in the medical branch. To me, passion is very important, and working at a place that you consider more a a hobby than a job is a big thing. What's the point of being an engineering student if you don't like math? So what's the point of going for medicine if you don't enjoy helping people? Is it because of the title? Well, you're NOT going to enjoy the rest of your life stuck in one place. If you find it amaing helping people and earning decent amount of money and STILL wanting to go back there and help more, than you've come to the right place, nothing else!

I also have a question or two about the job as a physician: Is it REALLY this way, as the people say, about the fact that you either choose your career or your family? In that case, what's the point of really existing if you spend 24/7 in a hospital, tired and having your bank filled with money?I understand that while there are people who don't care about money, you must be realistic about the fact that most of us want to live in a decent place and acctually enjoy life once or so. Helping people IS my passion, but sometimes I need my batteries re- charged, and if I can't even do that, than what's the point of even having a name or even have a girl/boyfriend of even a family for that matter? I find this whole "family/career"- dilemma really stupid, and if you really don't get any free time to spend with people who acctually care for you, that why even bother worrying about other peoples problems, when youve got your own at hand?

Sorry for this useless post, I'm just a really confused student who's got 6 more months to study at the engineering- preperation before I decide to either switch to medical or go along with engineering.

I don't think anyone is spending 24/7 at the hospital these days, nor did they in the past. I think the concept of shift work has gradually taken over for attending physicians too. By the time you finish med school and residency, you should be OK. Private practice will be a distant memory by then.